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The British Journal of General Practice is an international journal publishing research, debate and analysis, and clinical guidance for family practitioners and primary care researchers worldwide. The BJGP Blog brings opinion to research and clinical practice.

A GP’s experience of the Grenfell Tower fire


Ahmed Kazmi
is a GP at Exmoor Surgery in West London. He is also a stand up comedian and his next shows will be used to fundraise for the dispossessed. For tickets go to: www.doctorahmed.net and to donate: www.justgiving.com/doctorahmed. He is on Twitter @drahmedkazmi

London 15th June 2017. I am a GP working in the West London area. My clinic is less than 800 metres from Grenfell Towers and several of our patients were resident there.

The day after the fire was a tragic day for many and a very atypical day in our surgery. We spent it trying to compile a list of our patients who had been dispossessed. We made comfort calls to those affected, (especially the vulnerable ones), offered walk-in appointments for those who found themselves without medication and tried to offer some comfort. It is difficult though, what do you say to someone who has just lost their home and every possession they own? “I am so sorry for what has happened to you, here is your insulin prescription”.

I went down to help at the rescue centres. Walking past the towers was eerie. It looked like something from an apocalypse film. There were men in white biohazard suits, police and exhausted firemen. The building was still smoking. I was fearful what state the rescue centres would be in. I took a big breath and entered.

If this type of unity is possible in times of tragedy I think it is realistic to aim for it all the time.

I struggle to describe what I saw without getting emotional. I didn’t see or feel any despair or terror. The overwhelming feeling was of love, unity and solidarity. Every corner of St Clements Church and Rugby Portobello Trust were taken over by agencies there to help. A make shift housing office, a lost relatives bureau, the Red Cross, a doctor and nurse station to name a few. There were emergency services workers circulating the floor. I have never seen so many priests in one place (which is saying something considering I went to a Church school!), even the Bishop was there.

The most beautiful observation for me was the conduct of the local residents. People arrived one after the other, with food, clothes and toiletries. People quickly sorted the items and displayed them and helped the affected pack what supplies they needed into bags. A group of young black Muslim boys, who were fasting themselves, walked around with jumbo pizzas offering everyone slices. A group of ladies arrived to offer face painting for the children.

As a doctor I felt slightly redundant. There were so many doctors and nurses who had volunteered the centres were very well staffed. I sat down on the floor and played with some children. I asked a young boy if he wanted to do a jigsaw (he replied he didn’t like jigsaws). I asked why he had no teeth. He said the dentist took them; we both laughed. I didn’t use my stethoscope those hours I was at the centre, but I still feel I was a doctor. I think sometimes empathy and witnessing someone’s grief are as important a part of our role as procedures or prescribing.

It was striking how all of the usual prejudices or divisions which so frequently surface, were all suspended. People from all walks of life were empathetic and loving to each other. For a period at least people stopped being black, white, Muslim etc and were just ‘human’. If this type of unity is possible in times of tragedy I think it is realistic to aim for it all the time.

My story of everyday scholarship in general practice

Faraz Mughal is a GP in Birmingham and the RCGP Clinical Fellow in Children and Young People’s Mental Health. He is on Twitter: @farazhmughal

Making scholarship part of my daily practice contributes to the intellectual challenge and enjoyment of my work in general practice.

Self-harm affects 1 in 12 child or young people (CYP).1 Nearly 10% of 5-16 year-olds have a mental health illness which means in an average school class of 30 schoolchildren, three will suffer from a diagnosable mental health disorder. With increasing pressures facing young people in all aspects of their lives, the rates of mental illness are likely to rise. CYP mental health is thus a challenge for GPs everywhere.

At the frontline, we as GPs detect mental health illness; whether it presents as a physical health symptom, through parental/family concern, or simply an instinct you have when seeing a CYP in surgery. It is known that CYP with mental illness are twice as likely to attend to see their GP.1 Mental health is something we should be all thinking in every CYP we see.

But it can be an area of practice that we all find difficult, we can feel uncomfortable tackling this clinical area. Locally GPs have described, both personal issues (a lack of training) and service problems (difficulties accessing specialist services) as reasons for this.

In my own practice, I realised that there were limited resources available in this area and that accessing support from specialist services was difficult. I explored this further and realised others were experiencing similar problems. So, I began to think about how I could help address this, how I could improve my own practice while also helping the wider primary care community?

When RCGP advertised an opportunity to become the RCGP Clinical Fellow for CYP Mental Health I grabbed the chance to apply (these are regularly advertised through the RCGP so do keep an eye out!). Through this role, I have been part of an enthusiastic team developing quick-access resources for GPs and primary care staff to use in consultations with patients (accessed through the RCGP Mental Health Toolkit: http://www.rcgp.org.uk/clinical-and-research/toolkits/mental-health-toolkit.aspx). I also have the chance to influence policy through pushing for improvements in national and local services for CYP mental health. In addition, we have developed ‘TopTips’ articles for GPs on self-harm and eating disorders in CYP with more in the pipeline.

We are always thinking of how we can support GPs and if you would like to get involved with the college on working in this area, please do get in touch, we would be really pleased to hear from GPs and primary care professionals who want to work with us.

Reference:

1.     Department of Health. Future in mind: promoting, protecting, and improving our children and young people’s mental health and wellbeing. 2015. Available at: https://www.gov.uk/government/publications/improving-mental-health-services-for-young-people

You can read Revitalising general practice: unleashing our inner scholar by Joanne Reeve and Adam Firth at the BJGP here.

Self discovery with an ankle fracture

Kate Dawson is a full-time remote and rural ​GP on the Isle of Benbecula in the Outer Hebrides.

At our staff night out, I slipped on a wet dance-floor, and in a moment, fell and became a patient. I couldn’t put any weight on my foot, and my ankle swelled dramatically. As a consequence, I have learned a lot about myself, our systems, my colleagues, and about being a patient.

Our practice manager showed the most clinical acumen, and provided paracetamol and an icepack. The party continued as I watched from the side-lines,

I was on duty in A&E in our community hospital two days later and arranged for my ankle to be x-rayed. I knew there was something up when the radiologist asked me how much my ankle hurt; I had walked into the department, having done a full surgery. She confirmed that I had a comminuted fracture of my right ankle, in the run-up to Christmas, a time of year when medical locums are hard to find. I had an air-cast boot and crutches provided by the A&E nurse, and continued to the ward-round.

Three weeks later, the swelling was down but the orthopaedic surgeon was not happy, and I was admitted for open reduction and fixation in the Western Isles Hospital, adding another few weeks onto my recovery.

Firstly, I had no idea how much hard work it was using crutches. I had no problems with the co-ordination, but the strength required to walk more than ten yards is significant. My hands hurt, my shoulders were cramping up and my gluteal muscles had to learn how to balance me on my good leg. It took me quite a while to get to grips with this.

Secondly, my sisters both broke their wrists, and we have been able to compare notes about progress, the advice we were given and the progress we have made. It led me to examine the information and support we give to patients with common wrist and ankle fractures. The information that we have is quite brief, and focuses only on plaster care. Between the three of us, we have written four patient information leaflets, which are now being reviewed by a patient panel, plaster technicians, orthopaedic surgeons and physiotherapists. The aim is to adopt this board-wide.

The physios are very keen to be able to provide support with walking aids, exercises and treatment plans much earlier. We are meeting to discuss how we improve the pathway for patients with musculoskeletal injuries.

I am prone to doing everything myself, and I had to learn to ask for help.

Thirdly, the kindness that I experienced first-hand from colleagues and patients alike was wonderful. I am prone to doing everything myself, and I had to learn to ask for help. There is an art to this, making sure that your wishes are clearly expressed and the need for action described. Our wonderful practice manager rearranged the rota to cover my two weeks ‘resting’ with my leg up post-op, colleagues and locums all stepped up to fill the gaps.

Fourthly, I have learned that slowing down doesn’t mean that I do less. Instead of rushing around, sorting out everything in a whirl, I must plan my route through the day to take into account lifts, locations and tasks to be done. I have successfully ‘reabled’ myself by buying aids online, unbelievably cheaply, and remained independent where possible.

Lastly, this experience of being a patient has also illustrated very clearly how my agenda as a patient can be reframed by a few wise and confident words from a fellow professional. The orthopaedic surgeons and physiotherapists knew exactly how to motivate me into doing the right things, with good direct communication.

In exchange for a broken ankle, I have found my practice team to be kind and resilient, and I have developed the arts of patience, planning and delegation. I have started the improvement of the care that we offer patients with MKS limb injuries, anticipating better outcomes in the future.  My focus on good consulting skills is going through another cycle of improvement, and the cat is pleased too; I am sitting down more, and my lap is available more often.

Letter to Dr Sarah Wollaston – prevention of suicide and continuity of care

David Zigmond was a small practice GP in south London 1977-2016. You can
read Obituary for St James Church Surgery here.

This is an edited extract from a letter to Sarah Wollaston MP, Chair, Parliamentary Health Select Committee.

Prevention of Suicide. The crux of personal continuity of care

Late in December I heard a radio discussion (BBC Radio 4, Today) about how our community and its designated services might best prevent suicide. All the participants, including you, talked with clear sense about evident truths: our need for adequate (and increasing) funding, the need for skilled vigilance in primary care and in charitable organisations, easy access to joined-up, well-trained specialist services… No surprises and no real contention.

What I did not hear was anyone emphasising the importance throughout pastoral healthcare – so particularly with the desperately emotionally anguished – of personal continuity of care. No substantial attention was paid to the harm done by serial reforms and modernisations which, generally, have made such personal care increasingly difficult, now often impossible.

Pastoral healthcare has become increasingly misunderstood, neglected and impoverished.

Yet recognising and understanding these losses is essential for any therapeutic reparation and engagement. Since my medical qualification more than forty years ago the medical technologies have undoubtedly got better, but the healthcare relationships that administer these are often worse. How this has happened is complex: the consequences, certainly, are unintentional. The result is that, overall, treatments of structural diseases continues to improve, but pastoral (personal) healthcare – that which cannot be quickly fixed by technology – has become increasingly misunderstood, neglected and impoverished. Within this rubric mental healthcare is a prime example.

In the 1970s I worked as a young psychiatrist. Mostly we were able to provide a kind of flexible and personally attuned care with personal continuity, which has since been driven out by modern systems. This erstwhile care was largely provided by consultant-led general psychiatric ‘firms’ together with family doctors (rather than ‘primary care service providers’) who then worked in much smaller practices with identified patients (‘personal lists’). Both provided cornerstones where patients and practitioners could, through repeated and easier contact, develop bonds of naturally evolving personal knowledge and understanding. Most sufferers of mental health problems and experienced practitioners agree that such personal continuity is essential to the kinds of relationships that can enable first, trust and comfort, and then healing, repair and growth. This work is delicate and nuanced so becomes much more difficult – if not impossible – where there is not the time or context to develop these bonds. It can be helpful to see the evolution and nature of such bonds – between sufferers and healers – as bearing a close resemblance to those that evolve in well-functioning families: both are held together by developing relationships of trust and affection.

Such a ‘family’ ethos of providing pastoral healthcare has been made more and more unviable by our successive reforms and modernisations. With few exceptions, such ‘progress’ is defined by increasing systemisation so that the vagaries of personal meaning, relationship and attachment are replaced by rapid devices for ‘logical’ process: diagnosis, despatch and packaged intervention. Influence by bespoke individual understanding becomes displaced by generic prescribed ‘treatments’. But with this kind of human complexity we usually find that the greater our efforts of direct control, the less our understanding. If we are heedless of this we risk killing – however inadvertently – the human heart and natural habitat of our pastoral healthcare.

Modernisation programmes have become – paradoxically – antitherapeutic.

This change of care ethos from a kind of family nexus to a factory-like complex of contracted ‘service providers’ has increased massively in the last two decades – the last half of my long career in Psychiatry and General Practice. In that time I have seen now both services have become depersonalised in proportion to their systemisation. What does this mean? Increasingly, people do not know one another: contacts more rarely become deeper relationships, not just between doctors and patients, but also between colleagues. Data storage and transfer may be rapid and complete, but the slower, subtler, human processes of growing meaningful attachment, affection and containment have been largely driven out by our reforms. So such modernisation programmes have become – paradoxically – antitherapeutic. Hundreds of conversations I have had with older practitioners and patients support this view – the exceptions are apologist colleagues in management posts.

What are the devices that have transformed our healthcare family into a factory: from understanding natural processes to driving industrial protocols?

One source is our illusion that we can treat healthcare as a commodity, utility or manufactured object. From this other things have necessarily evolved: a consumerist view, attempts to monetise and proceduralise all care so that it can be commissioned, traded and controlled. Hence the Internal Market, the purchaser-provider split, autarkic competing NHS Trusts, Clinical Commissioning Groups, commercial-type incentivisations, the Health and Social Care Act (2012) … the list continues to grow. We have been very clever at fashioning such reforms, but very unwise not to see an ineluctable flaw: their destructive human and social effects.

This dehumanising systemisation of services is seriously demoralising and has led to our poor staff recruitment, sickness, drop-out, burnout, premature retirement … and suicide.

Our corner-stoned 4Cs – competition, commissioning, commodification and computerisation – have all been much vaunted as assuring more accountable, equitable and efficient healthcare yet have rendered us general practice and mental health services with poorer human contact, engagement and attachment. This dehumanising systemisation of services is seriously demoralising for staff. The work becomes increasingly stressed and impoverished of deeper (human) satisfaction: this has led to our poor staff recruitment, sickness, drop-out, burnout, premature retirement … and suicide. How can complexly distressed patients possibly do well in a service that is itself so sick?

In the last few years of my work in the NHS I have found it increasingly difficult to offer the kind of personally synergistic, comforting, containing, healing work I used to manage so readily with colleagues. The reasons for this are largely found in our organisational reforms – the kind of thing I have outlined above. Potential suicides pose our trickiest and starkest healthcare questions and tasks. There is always more to think about, to do and undo.

HEE budget slashed – turning NHS crisis into a catastrophe

Sunil BhanotSunil Bhanot is a GP partner in Hampshire, trainer, appraiser and member of RCGP Council.

Our NHS is about to lurch from crisis to catastrophe. Our capacity to change and cope with increasing demand is going to be undermined. Health Education England’s budget is being slashed by 30% from next month. I fear that this will have a significant impact on GP training and the transformation of the whole NHS workforce in moving towards a sustainable health care service.

It is only recently that this massive reduction in funding has been confirmed, planning has begun and it is becoming apparent that there is increasing central pressure from HM Treasury for it to be implemented by the end of the next financial year. HEE staff around the country have received emails asking them to consider voluntary redundancy and reply by 6th March.

As it is becoming common place in our NHS, professional and public consultation has again been neglected. The worst day in the lives of many leading educators has been smothered by the secrecy of contractual obligations so that they have to deny even the possibility that there may be negative implications of the cuts. It is this very lack of transparency and honesty that puts at risk patient safety, the quality of care that we are able to provide and trust in everything that we do in our NHS.

Talking to many leading educational colleagues from around the country, they are shaken to the core but are unable to share their significant concerns and have to try to exude external confidence and calm and keep smiling. This is no way to treat hard-working, dedicated and committed HEE staff who are passionate about our NHS ethos.

Educational colleagues are shaken to the core but are unable to share their significant concerns.

On its website, HEE states that it exists for one reason only, “to support the delivery of excellent healthcare and health improvement to the patients and public of England by ensuring that the workforce of today and tomorrow has the right numbers, skills, values and behaviours”. While the CQC talks of an NHS “burning platform” which is not fit for the future and the King’s Fund about the “credibility” of the STPs, we are about to destroy any potential for regeneration. I suggest that a 30% cut in the HEE budget will harm all our efforts to deliver the promise of progress.

The “Five Year Forward View” and the Sustainability and Transformation Plans require a workforce that has enhanced training, is flexible, efficient and effective and remains motivated to continue to learn and develop, focusing on improving the quality of patient care. This needs investment in education, training and professional development not just the articulation of hopes and aspirations followed by a kick in the teeth. There is immense pressure to increase the number of doctors, nurses and allied professionals in our NHS especially with Brexit. The challenge to develop different ways of working and retain our workforce is equally daunting. And I doubt that the Chancellor will mention the cuts in next week’s Budget statement.

I am asking for an open and honest conversation, decent engagement with the profession and the public, on the challenges and opportunities to transform our NHS with our limited resources for learning and teaching. I’m asking the RCGP, other Royal Colleges, GPC and the BMA to share our concerns with HEE, our Health Secretary, HM Treasury and the Prime Minister. We need to work with Simon Stevens, Chief Executive of NHS England to explore an alternative way forward.

I am not looking for sympathy and warm words, but I am asking for a pause and some time to consider the truthful and real implications. And, therefore, please RCGP and BMA, publish and share the responses that you get.

General practice in Scotland and Australia: the experience of two GPs

Jane Gall and Derek Wooff, are both general practitioners who worked in Stranraer, Scotland for 26 years and have been working in Shepparton Medical Centre for the last 6 years.

General practice is a good job. It uses knowledge, experience, judgement and intuition to provide appropriate care and this complex process is both stimulating and rewarding. Currently with rising patient expectations and decreasing investment, solutions to workload issues may benefit from broader thinking and looking to other models of care.

We wish to reflect on our experience of translating care from the NHS in Scotland to Medicare in Australia.

We became emotionally exhausted attempting to continue providing the level of care expected by the population. 

Our background was working as general practitioners (GPs) for 26 years within the NHS model of care based in Stranraer, a small town in Scotland. We knew our patients and their families extremely well. We were truly part of a team with practice nurses, linking with district nursing staff and being part of the community hospital. This involvement provided professional satisfaction and support from a multidisciplinary team. There were many changes over the years and the team structure of General Practice allowed moulding and restructuring to changing demands. However, we became emotionally exhausted attempting to continue providing the level of care expected by the population with decreasing resources and increasing clinical governance. It was hard to manage workload and demand as well as fulfil the QOF (Quality and Outcome Framework) criteria and paperwork. It seemed the fun of the job had decreased with the doctor agenda rather than the patient agenda driving the consultations. We were concerned about moving out of our comfort familiar zone and working elsewhere without the ‘safety’ of background knowledge of patients and relationships that had developed from years of continuity of care.

Could we re-establish our professional satisfaction and feel the fun again of general practice by moving continent?

In 2010 we moved to Australia and took the opportunity of developing a medical student teaching GP clinic, which was a new development for the University of Melbourne. This challenge was growing a general practice business in Shepparton, a regional town in Victoria, Australia, within the Medicare system. When this opportunity arose for a ‘sea change’, we decided to take the plunge. Interestingly we found change and new beginnings are normal in the Aussie culture.

Adapting to a new model of care has been refreshing and interesting. Firstly, we realised that the therapeutic relationships with patients we value so much and had felt were partly built on years of continuity of care can be established quickly within a consult. This may be aided by years of experience although I do believe that active listening skills are the key. Trust can be felt at the consultation and so it can be a surprise when despite this patients do move around for care. The GP model of care in Australia allows patients to go to any GP practice at any time, so ongoing relationship care is viewed differently by both the patient and the professional.

We have considered the impact of this fundamental difference between the NHS and Australia primary care. The Australian system does encourage patients to take more ownership of their own care although it may result in over servicing and unnecessary repeat investigations. However, the GP is freed from the trapped feeling of patients being dependent on him or her as an individual. Patient autonomy and ability to seek second opinions is almost encouraged and facilitated in Australia. This can be releasing and helpful, although potentially confusing and may result in patients searching for the response desired by the patient. As there is little effective transfer of information or central data base to connect patient information, decisions can be made within silos of thinking.

Perhaps care could be considered in different contexts; acute and chronic. Acute consults sometimes including incidental task oriented requests like forms or repeat prescriptions and ‘chronic’ for more complex ongoing illness review. It appears that some patients seem to value continuity of care for chronic disease, while attending different ‘convenient’ practices for incidental or acute care. In some regard this does make sense as good background knowledge of medication tried and pathology results may be more important for management of chronic conditions.

The flexibility of provider of care allowed to each patient does alter the fundamental role of GP as the hub of the wheel and ‘gatekeeper’ that is strong in the UK model of general practice. The GP is part of the care, but not the truly essential coordinator in Australia. As stated, the care may then be inappropriate or with duplication at times but it can also provide appropriate convenient care, for example, antibiotics for a UTI in a timely and accessible manner at a consult near the where the patient may be shopping. However, there is no real way of stewardship of the public purse which will be providing Medicare back up payments for many visits.

In the NHS… some shift to patients accepting some accountability for their own care would be good to see.

Currently there are ‘care plans’ and ‘team care arrangements’ under the Australian Medicare scheme. These are used for ongoing complex illness and team care is for co-ordinating allied health referrals. This model applies well to some cases – for example patients with diabetes. It does encourage goal setting for individual patients with their ‘regular’ GP and review can be three monthly. The emphasis is focused on the individual patient in contrast to the QOF points in the NHS model which is doctor agenda and population care driven. Also there is current discussion regarding the ‘my medical home’ model in Australia to further incentivise care by one GP. This may help address some of the duplication and rationalise ongoing responsibility. I believe this may be of benefit particularly to the most vulnerable such as mentally unwell patients who may slip through the net. The responsibility by the GP in the NHS can be over-burdensome and some shift to patients accepting some accountability for their own care would be good to see, particularly given the current recruitment crisis of GPs in the UK. This requires understanding from society and a change from people feeling that totally comprehensive care is a right to encouraging capable individuals to play a more active part in their healthcare. GPs may then feel less trapped in impossible positions within the NHS model of care.

A huge learning area for us has been understanding the business financial differences within general practice in the two countries. The curious bit is considering how this affects care delivery both from a patient ‘consumer’ perspective and from the professional point of view. Our practice in Australia followed a ‘bulk billing’ model until recently. This model survived on Medicare rebate income from item of service and was effectively free to patients. Translating across from the NHS, this model fitted our beliefs of having no barriers to accessing primary care. However, we have now a deeper understanding of Australian Medicare and appreciate this government support is essentially present for those who have healthcare cards and so fit the criteria for free care. Interestingly, others often wish to pay their way as part of their expectation and own feeling of self-worth, not misusing the ‘free’ system. This seemed to us an interesting cultural shift from the British feeling of their rights as they have paid taxes to the Australian view where they feel it is appropriate to contribute and often have a higher regard of value when linked to a higher cost. However, there are some patients on the borderline for ‘healthcare cards’ which is the entitlement to free care and so are charged for consults thus may find cost a barrier to seeking appropriate primary health care. Using judgement to allow bulk billing could allow discretion to the most vulnerable but still lacks the guarantee of access to primary care for all. We do believe access to primary care is a fundamental right and it is a professional duty to manage this demand supported by broad discussion with society.

Our view is that there is value in adopting the best of both models of care.

The concept of ‘my medical home’ with continuity of care for patients with chronic illness while still allowing patients to access convenient care for acute problems may be a hybrid that could be considered. Ideally some linkage of electronic health records would support some mobility of patients and safety net patient care, while helping to reduce duplication and unnecessary investigations. This is truly a challenge for health care everywhere.

Moving to Australia has refreshed us professionally and allowed us space to reflect on and appreciate the robust system of general practice in Scotland.

Within the consultation, a focus on patient driven agenda with individual patient health goals is important. This may result in more engagement and accountability by individual patients and some of the dependency which exhausts individual general practitioners would be alleviated. One challenge is how to maintain clinical governance and standards of care within such a wide scope of work. Measuring outcomes can miss valuing the skills of navigating multiple co morbidities and providing appropriate holistic care. Knowledge and skills that are hard to define or measure are key to implementing appropriate individual care.

The engagement with individual patients resulting in improved professional satisfaction is still possible and the fun can certainly bubble up again. Recognition of the importance of primary care and managing public expectations are key to helping the bubbles rise up again. Moving to Australia has refreshed us professionally and allowed us space to reflect on and appreciate the robust system of general practice in Scotland. However, general practice in Scotland would benefit from review to alleviate the exhaustion of unrealistic patient demands and impossible society expectations. General practice is a complex job so any adjustments are complex but without recognition of the value of the job along with adaptation and changes to the job, there is a risk of loss of the essence, fun, effectiveness and professional satisfaction for the next generation.

General practice is still a wonderful job.

“Too big to talk about”: Organisational momentum and its paralytic wake

David Zigmond was a small practice GP in south London 1977-2016. You can
read Obituary for St James Church Surgery here.

Corporatism often enlarges and entrenches itself by increasing demands for compliance. Eventually though, unchecked, this will sicken any organisation. Such is now evidently ailing our NHS. A brief glimpse from a small conference provides a sample.

November 2016, London. A small conference of (mostly junior) doctors. The brief: to better survive the increasing stresses of their work. They are being mentored, guided, enabled and reassured by evidently concerned and sympathetic senior clinicians and cohort managers.

Supportive, ventilatory and distracting strategies are suggested: these may palliate, encourage and help endurance.

Discussion turns to appraisals: how tiring, gruelling, dispiriting and stressful they are.

Discussion turns to appraisals: how tiring, gruelling, dispiriting and stressful they are. An older patrician-clinician, Dr O, is able to reassure with statesmanlike knowledge and know-how. Yes, appraisals are an unpleasant, inordinate and major stress for many doctors, Dr O agrees. But he can personally help with this: he knows how the system operates, and who operates it: Dr X, for example. Dr X is very senior in the appraisal hierarchy and wants to be helpful to our many needlessly and haplessly struggling doctors. He can pass on many tricks, feints and shortcuts to neutralise the formidable administrative obstacles and find easier ways to demonstrate the compliance now essential for professional survival. Yes, Dr O continued, these are testing and perilous times but there are those – like Dr X – who will provide sanctuary, ‘a safe house’, help with ersatz documentation. The important thing is that we find ways to tender what we must: to survive.

As I listen to these exchanges I recall heroic stories from World War II: of resistance movements stealthily sheltering, then smuggling to safety, downed allied airmen; of Oscar Schindler duplicitly providing false documentation and work to protect those otherwise doomed. Dr X seemed, to me, like Schindler and Dr O his discrete emissary.

All these efforts, albeit unintentionally, perpetuate a bad and destructive system.

I admired all these caring and protective seniors and the responsibility they showed for the welfare and survival of their juniors. Yet I was doubtful of the larger benefit that would come from these sincere and substantial efforts: to help these tired and craven doctors to pass muster, comply to regulations they experience as draconian, and then survive-by-adaptation with the mandatory documentation. All these efforts, albeit unintentionally, perpetuate a bad and destructive system. Adaptation via obedience can easily turn to collusion.

I attempted, with respectful diplomacy, to say this. I summarised briefly: “I really like the comforting care, support and healing that’s being offered between you. But something much bigger is being ignored: the unsustainable, toxic and oppressive environment we all have to work in. These forces overwhelm and fatally undertow all our attempts to mitigate or repair…”

I had wanted to offer a brief profile of the component-agents of our pathogenic healthcare culture: how the 4Cs – commercialisation, commodification, corporatisation and computerisation – are driving out the human and vocational heart of our work; how our erstwhile (mostly) humanly gratified professional ‘families’ are displaced by managerially driven and depersonalised systems of ‘factories’; how our health services’ administrative devices all drive the larger system that is so ailing and alienating us. The entire Internal Market, Commissioning and Inspection cultures, in their many guises, all contribute: autarkic NHS Trusts, financially-based competitive commissioning; burgeoning performance-related targets with their necessary machinery for monitoring, data, negotiation and penalties; the resulting, ever-increasing need for compliance, surveillance, policing, documentation and (to mop up any surviving outliers) strictly regulated professional appraisal and validation …

But the chairperson arrested the beginning of this flow. She judged it well beyond the scope of this meeting: how may clinicians now best survive?

***

During a short break a veteran manager approaches me. “I know what you want to say. Almost everyone here would agree with you. But there’s nothing we can do about these things: they are far too big for us to influence them”, she says with fraternal commiseration. “In any case, this is not the right forum”, she adds with cautioning advice.

“Well, there never is a ‘right forum’ for discussion of these crucial things now. This recurrent exclusion is not accidental. It is the tip of a systemic iceberg: it tells us much about the size and nature of our problems. Paradoxically, our lack of open discussion indicates why we must talk candidly. And if not now, when?”, I replied.

The manager seems attentive to this but says nothing. She meets my gaze and offers me a brief smile. To me this seemed unjoyfully complex: contrition, appeasement, fear, alliance, apology, irony and respectful pity. I smiled back, wondering what she saw.

She turned to join Dr O. They re-entered the conference room.

—–0—–

Interested? Many articles exploring similar themes are available via David Zigmond’s home page on www.marco-learningsystems.com

 

Arclight: a new ophthalmoscope and otoscope

John PorterJohn Porter recently completed his GP training and is enjoying living in Bath and working as a salaried GP in Bristol.

There are items of equipment without which a GP in clinic cannot function. Top of this list comes a stethoscope. Closely followed by an ophthalmoscope or otoscope.

As I neared the end of GP specialist training the time was nearing to hand back the practice supplied equipment and to put a hand in my pocket and buy an ophthalmoscope/otoscope of my own. A few hundred pounds, this tends to be the most expensive item needed to get started after training.

With my credit card about to take the hit I got talking to a friend who had returned from working as a doctor in Uganda and was continuing to use a novel ophthalmoscope/otoscope designed for use in developing world environments in his work as a NHS hospital doctor.

After giving it a once over my initial impression was that the Arclight device worked well. (www.arclightscope.com). I could see the benefits the novel lightweight device would have when used in areas of the world where its inexpensive price and the lack of need for batteries is an advantage, and wondered if it also had a place in the bags of GPs in the UK.

Out of personal interest in low cost and innovative technology I acquired and distributed 36 devices to both qualified GPs and final year trainees to find out more (mean clinical experience was 11 years).

I started with questionnaires to gain insight into what GPs thought of their current kit. What I found was that the vast majority of GPs who took part used their ophthalmoscope between 5 to 10 times per week. Their confidence in ophthalmoscopy using their regular devices was 6.4/10 (mean), with a range of 4/10 to 9/10 (1 being no confidence and 10 being very confident). In otoscopy confidence was 7.8/10 (mean) and ranged from 6/10 to 10/10. Problems with batteries and bulbs, being cumbersome to take on visits and expense were widely shared complaints.

Arclight devices were trialled in clinics for 6 weeks. End questionnaires found confidence in ophthalmoscopy using Arclight scopes was 6.9/10 (mean), a range from 3/10 to 9/10. Confidence in using the Arclight scope for otoscopy was 8.1/10 (mean) and ranged from 6/10 to 10/10.

Users found that the Arclight scope’s light weight and small size was beneficial to them in general practice, as were the bright LED lights which were found to stay consistency bright. Suggestions for improvements in the device included making USB charging less fiddly and improving the stability of the otoscope ear pieces when fitted. 75% of users said they would continue using this device after this trial and 92% would recommend the device to a friend.

Outcome

It would appear that the Arclight ophthalmoscope and otoscope device would be very welcome in GP bags (and I would anticipate around the necks of hospital doctors and medical students).

Interestingly I found user confidence with the Arclight scope better than that reported from the traditionally used more expensive and cumbersome devices without their frequently encountered battery and bulb problems.

Dr John W Porter, GP, Kingswood Health Centre, Bristol & Dr Keir EJ Philip, Core Medical Trainee, Barts Health NHS Trust.

Of note neither I nor my friend Keir Philip have interest invested financially or otherwise in Arclight ophthalmoscope/otoscope devices, we’re just intrigued by this sort of thing!

Top 10 most read BJGP research articles published in 2016

16Jan_Top10_research_2015_BJGP_smThese are the top 10 most read research articles based on full text downloads from bjgp.org in 2016.

1. Overdiagnosis of asthma in children in primary care: a retrospective analysis. 
http://bjgp.org/content/66/644/e152

Overdiagnosis of childhood asthma is common in primary care, leading to unnecessary treatment, disease burden, and impact on quality of life. However, only in a small percentage of children is a diagnosis of asthma confirmed by lung function tests.

2. Telephone triage systems in UK general practice: analysis of consultation duration during the index day in a pragmatic randomised controlled trial. 
http://bjgp.org/content/66/644/e214

Telephone triage is not associated with a reduction in overall clinician contact time during the index day. Nurse-led triage is associated with a reduction in GP contact time but with an overall increase in clinician contact time. Individual practices may wish to interpret the findings in the context of the available skill mix of clinicians.

3. Primary care clinician antibiotic prescribing decisions in consultations for children with RTIs: a qualitative interview study.
http://bjgp.org/content/66/644/e207

Prognostic uncertainty remains an important driver of health care professionals’ antibiotic prescribing. Experience and training in recognising severe respiratory tract infections (RTIs), together with more evidence to help professionals identify the children at risk of future illness deterioration, may support identification of the children most and least likely to benefit from antibiotics.

4. Continuity of care in primary care and association with survival in older people: a 17-year prospective cohort study.
http://bjgp.org/content/66/649/e531

This study demonstrates that low continuity of care in general practice is associated with a higher risk of mortality, strengthening the case for encouragement of continuity of care.

5. Nursery sickness policies and their influence on prescribing for conjunctivitis: audit and questionnaire survey.
http://bjgp.org/content/66/650/e674

Most of the childcare providers’ sickness policies contain requirements that are inconsistent with Public Health England guidance. The requirements of childcare sickness policies are likely to be resulting in unnecessary primary care consultations and thousands of prescriptions for antibiotics with little demonstrable clinical or public health benefit.

6. Unrecognised bipolar disorder among UK primary care patients prescribed antidepressants: an observational study.
http://bjgp.org/content/66/643/e71

Among people aged 16–40 years prescribed antidepressants in primary care for depression or anxiety, there is a substantial proportion with unrecognised bipolar disorder. When seeing patients with depression or anxiety disorder, particularly when they are young or not doing well, clinicians should review the life history for evidence of unrecognised bipolar disorder. Some clinicians might find the Mood Disorder Questionnaire to be a useful supplement to non-standardised questioning.

7. Identifying depression among adolescents using three key questions: a validation study in primary care.
http://bjgp.org/content/66/643/e65

Depression in teenagers can have serious consequences and the incidence seems to be increasing. Three short questions, suitable for use in general practice, are useful for identifying depression in adolescents in primary health care.

8. Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review.
http://bjgp.org/content/66/643/e114

Although resources are important, many barriers to improving care are amenable to behaviour change strategies. Improvement strategies need to account for differences between clinical targets and consider tailored rather than ‘one size fits all’ approaches. Training targeting knowledge is necessary but insufficient to bring about major change; approaches to improve diabetes care need to delineate roles and responsibilities, and address clinicians’ skills and emotions around treatment intensification and facilitation of patient behaviour change.

9. Comparison of brief interventions in primary care on smoking and excessive alcohol consumption: a population survey in England.
http://bjgp.org/content/66/642/e1

Whereas approximately half of smokers in England visiting their GP in the past year report having received advice on cessation, less than 10% of those who drink excessively report having received advice on their alcohol consumption.

10. Molluscum contagiosum and associations with atopic eczema in children: a retrospective longitudinal study in primary care.
http://bjgp.org/content/66/642/e53

Consultations for molluscum contagiosum in primary care are common, especially in 1–9-year-olds, but they declined significantly during the decade under study. A primary care diagnosis of atopic eczema is associated with an increased risk of a subsequent primary care diagnosis of molluscum contagiosum.

 

Child & Adolescent Mental Health Problems – Twitter Journal Club

img_4397Carrie Ladd is a part time NHS GP, a spare time RCGP Clinical Fellow in Perinatal Mental Health and a full time mum… doing overtime! You can find her on Twitter @LaddCar and she has a website.

On Sunday 28th November, Dr Lucy Pocock and I co-hosted a session of the Twitter based journal club #gpjc to discuss one of the emerging priority areas of General Practice – Child and Young People’s Mental Health. The BJGP paper we discussed was a systematic review of primary care practitioner’s perceptions to barriers in managing these problems. All contributors seemed to agree that GPs are seeing more and more cases of mental health problems in adolescents but there was some debate as to whether this piece taught us anything new about the challenges we face in supporting these young people.screen-shot-2016-12-05-at-14-36-21

The themes identified in this review as ‘barriers’ were familiar to those joining the discussion and they are in common with most other mental health sub-specialities. Fear of judgement or stigma may limit disclosure, concerns over confidentiality may limit discussion and lack of referral options locally may restrict what help is available. This review also highlighted a lack of confidence in GPs themselves recognising childhood mental health problems and this may prove a springboard piece of work to address this unmet need in the near future.

This was a large systematic review covering 4151 articles in initial stages with 43 being looked at in detail – 30 quantitative and 13 qualitative. The articles were from a range of countries and one of the points in our discussion questioned whether this undermined or strengthened the validity of the results. Although Australia and Ireland could be seen to have similar health systems/ socioeconomic factors to the UK, perhaps South Africa and Puerto Rico less so? Also many of these studies were not specifically GPs but paediatrics as well which is important to be aware of.

In the final section of the discussion, we looked at how we can mitigate these barriers and collaboration seemed a key theme. Several people suggested better lines of communication with our mental health colleagues. Quarterly MDTs between psychiatry/CMHT & the GP practice, Psychiatry colleagues spending a day a week in General Practice is being done in one innovative GP surgery. In another great example of collaborative working, a specialist eating disorder therapist is based in a predominantly University Population Bristol based GP practice.

Finally, close of discussion included signposting to the RCGP Mental Health Toolkit which is available free, open access to all and mention of Young Minds and MindEd resources which are well worth a look up if new to you. The conversation continued after the scheduled hour and the 10 minute consultation model was cast aside as not fit for purpose when a patient comes to talk about mental health problems with longer appointments welcomed by the #gpjc group.

It is clear that from the GPs who joined the discussions on Sunday, this is an area of general practice we could do better, and we need to galvanise interest and support for a society wide movement to raise awareness and prompt further investment in Child and Young People’s Mental Health services.

If you haven’t popped over on a Sunday evening, check out @GPjournalclub for their monthly discussion group – see you there.